Arguing about e-cigarettes – a Q&A

e-smoking ban-resized-600

Danger: Prohibitionists on the march

Here is a set of questions and answers on e-cigarette science, policy and politics.  Please use the comments to suggest other questions, better answers or to pick me up if I’m wrong.

1. What is in the exhaled vapour and is it harmful to other people?
2. Does nicotine cause cancer or other health effects?
3. Does introduction of e-cigarettes have the effect of increasing smoking?
4. Is vaping a gateway to smoking for kids?
5. Are e-cigarettes just ‘renormalising’ smoking?
6. Can e-cigarettes save lives?
7. Do e-cigarette help people quit smoking?
8. Do people who switch continue vaping or move on to quit altogether?
9. The Minister of Health is not convinced of the safety of e-cigarettes – what now?
10. A health organisation has said ‘we just don’t know what’s in them’ – do we really know so little?
11. Shouldn’t people who want to quit smoking use licensed smoking cessation medicines like NRT?
12. Shouldn’t we just ban vaping indoors as we have done with smoking?
13. E-cigarette advertising is targeted at children and should be banned
14. Nicotine is a powerful poison and needs to be strictly controlled or outlawed
15. The tobacco industry is involved and they will want to force smokers to keep smoking
16. We are going to clamp down on e-cigarettes in hospitals
17. A doctor is saying nicotine is as addictive as crack cocaine, and that tobacco is just like a syringe for nicotine
18. The long term effects of inhaling e-cigarettes are not known. Should they not be restricted until it is known they are safe for continuous use?
19. E-cigarettes should be regulated as medicines to guarantee safety, quality and efficacy
20. What if the critics of e-cigarettes are wrong?
21. “E-cigarettes contain [rat poison][weed killer][anti-freeze][carcinogens][insert scary sounding chemical here]”
22. The ultimate public health aim is to remove reliance on nicotine entirely
23. New Those flavours are there to attract children
Appendix. How well is Ireland doing on tobacco and health?

1. What is in the exhaled vapour and is it harmful to other people?

In the  exhaled vapour there’s some vapour base (an ‘excipient’ like propylene glycol), a little nicotine, some water vapour and some flavours that might impart an aroma.  There may be some breakdown products or traces of contaminants.  The things that lead to concern about second hand tobacco smoke are either absent, undetectable or present in very low concentrations. The most comprehensive review so far concludes that active vaping poses near negligible risk, and that second hand exposure would be ‘orders of magnitude’ less.:

Current state of knowledge about chemistry of liquids and aerosols associated with electronic cigarettes indicates that there is no evidence that vaping produces inhalable exposures to contaminants of the aerosol that would warrant health concerns by the standards that are used to ensure safety of workplaces. However, the aerosol generated during vaping as a whole (contaminants plus declared ingredients) creates personal exposures that would justify surveillance of health among exposed persons in conjunction with investigation of means to keep any adverse health effects as low as reasonably achievable. Exposures of bystanders are likely to be orders of magnitude less, and thus pose no apparent concern. (emphasis added)

(Burstyn I, 2013)  Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks

2.  Does nicotine cause cancer or other health effects?

No.  There is no evidence that nicotine causes cancer – and it is really for those that make the claim to show that there is. It is possible that nicotine is unhelpful in treatment or recovery if you already have cancer.  It’s the smoke – the smouldering particles of organic material and hot toxic gases – that does the damage.  Professor John Britton, who is Director of the UK Centre on Tobacco and Alcohol Studies and heads the Royal College of Physicians Tobacco Advisory Group compares the health risks of nicotine to caffeine.

“Nicotine itself is not a particularly hazardous drug,” says Professor John Britton, who leads the tobacco advisory group for the Royal College of Physicians.

“It’s something on a par with the effects you get from caffeine.

“If all the smokers in Britain stopped smoking cigarettes and started smoking e-cigarettes we would save 5 million deaths in people who are alive today. It’s a massive potential public health prize.”  (BBC, Feb 2013)

Like caffeine, nicotine has effects on the cardiovascular system: raising heart rate and blood pressure.  There is also concern that it has impact on foetal development. The harms caused by smoking have often been confused with nicotine and it is inherently hard to study the impact of nicotine itself in smokers because there are so many other substances the smoker is exposed to at the same time.  Fortunately, there has been extensive research into the health risks of nicotine because of its use in a licensed medical product, NRT.  The Royal College of Physicians Tobacco Advisory Group surveyed the literature in 2007 (RCP, Harm reduction in nicotine addiction) and concluded the chapter on medicinal nicotine:

  • Extensive experience with nicotine replacement therapy in clinical trial and observational study settings demonstrates that medicinal nicotine is a very safe drug.
  • Adverse effects are primarily local and specific to the mode of delivery used.
  • NRT does not appear to provoke acute cardiovascular events, even in people with pre-existing cardiovascular disease.
  • There is no direct evidence that NRT therapy is carcinogenic or influences the risk of other common smoking-related diseases in humans.
  • Evidence on the safety of NRT during pregnancy is limited, but suggests that NRT does not increase the risk of major developmental anomalies or reduce birth weight. However, NRT may increase the risk of minor musculoskeletal anomalies. Further evidence on these effects is needed.
  • Evidence on the safety of long-term use of NRT is lacking, but there are no grounds to suspect appreciable long-term adverse effects on health.
  • In any circumstance, the use of NRT is many orders of magnitude safer than smoking

 Health benefits? There is also evidence nicotine may have health benefits, for example in reducing weight, protecting against Parkinson’s disease and improving cognitive function – see CASAA’s page on this for sources.

Detriment of withdrawal and craving. Withdrawal from nicotine use may be disruptive and unpleasant – and and such has a negative effect on health and wellbeing.  So use of nicotine in people who quit smoking has the health benefit of avoid at least some of the withdrawal and craving.  That is one reason why the prospects for e-cigarettes are so promising: it can provide many of the benefits people perceive in smoking, but with few of the impacts, while avoiding the unpleasant experience of quitting completely – and at lower cost.  That value proposition gets stronger as each month goes by.

3.  Does introduction of e-cigarettes have the effect of increasing smoking?

No – there is no evidence to support this. People who don’t like vaping for other reasons try to use this argument to suggest that a product that is many times less risky than cigarettes can somehow become more dangerous, because it somehow prevents people from quitting.  The same sort of people used the same arguments were used to get Swedish snus banned in the EU in 1992, even though it is probably 98-99% less risk. The snus ban wasn’t applied in Sweden, which now has by far the lowest rates of smoking in the EU and lowest rates of smoking related disease. In Sweden, people used snus to quit smoking, to displace cigarettes or instead of starting to smoke (see letter from experts: why is EU banning Europe’s most effective response to smoking?).   On e-cigarettes, the survey data is now coming in and showing pretty much the same thing – take this one The Guardian reporting on the survey by ASH (UK)

But Ash’s survey, carried out by YouGov, suggests this is not happening and that people are using e-cigarettes to kick their tobacco habit instead.

“The dramatic rise in the use of electronic cigarettes over the past four years suggests that smokers are increasingly turning to these devices to help them cut down or quit smoking. Significantly, usage among non-smokers remains negligible,” said Deborah Arnott, Ash’s chief executive. (Guardian)

4. Is vaping a gateway to smoking for kids?

No, despite a great deal of hype from the US, the facts are very different.  Although there is a rise in e-cigarette use among school age adolescents, that does not prove anything bad is happening – it simply mirrors what is going on in adult society. Whether it is harmful depends what you think would have happened in the absence of e-cigarettes.  It is quite possible that e-cigarette use is displacing smoking in adolescents. Even where they have never smoked it might be acting as an alternative to taking up smoking. For there to be any real harm, you would need to show that students were taking up vaping and then going on to develop a life-long smoking habit, because of the vaping.  In fact in the data presented from the US there were much more encouraging signs: e-cigarette use was a small fraction of the smoking rate among school students; the rise of e-cigarette use coincided with a much larger drop in smoking; and e-cigarettes use was concentrated among those already smoking.  Here is the full picture in graphic form, and you can read more discussion on the bogus claims for gateway effects in my ‘Cease and desist’ letter to scientists trying to perpetrate this fraud and a background discussion on ‘gateway effects’: we need to talk about the children: the gateway effect examined.

US NYTS data

5. Are e-cigarettes just ‘renormalising’ smoking?

The people who claim this need to explain carefully how they think one activity can normalise another, especially when these alternatives involve products in competition.  It is more likely, and should be assumed in the absence of evidence to the contrary, that vaping normalises vaping, which is an alternative to smoking – and therefore normalises not smoking. High level support for this comes from one of the world’s experts in smoking cessation, based on UK survey data:

Evidence conflicts with the view that electronic cigarettes are undermining tobacco control or ‘renormalizing’ smoking, and they may be contributing to a reduction in smoking prevalence through increased success at quitting smoking

(Professor Robert West: Trends in e-cigarette use, presentation to European Conference on Tobacco or Health)

6. Can e-cigarettes save lives?

This is a matter of simple logic.  If smoking is dangerous and may kill potentially one billion people in the 21st Century, then if people substitute cigarettes for products that do not have the main thing that causes the risks (burning organic material and inhalation of smoke) then they will be at greatly reduced risk.  It’s hard to know exactly what the risks are relative to smoking – some people can see no obvious pathway whereby they would cause death.  One expert ‘multi-criteria decision analysis’ put the health risks at around 1% (or 3% if you include ‘addiction’ as a health risk, which is a debating point).  This is how they compare different nicotine products (Nutt D et al, 2014) – e-cigarettes are included in ENDS – electronic nicotine delivery systems:

Screen Shot 2014-04-04 at 12.28.42

Fifty three scientists and other experts wrote to the WHO Director General, Margaret Chan to say in their letter of 26 May 2014:

There are now rapid developments in nicotine-based products that can effectively substitute for cigarettes but with very low risks. These include for example, e-cigarettes and other vapour products, low-nitrosamine smokeless tobacco such as snus, and other low-risk non-combustible nicotine or tobacco products that may become viable alternatives to smoking in the future. Taken together, these tobacco harm reduction products could play a significant role in meeting the 2025 UN non-communicable disease (NCD) objectives by driving down smoking prevalence and cigarette consumption.

[…]

The potential for tobacco harm reduction products to reduce the burden of smoking related disease is very large, and these products could be among the most significant health innovations of the 21st Century – perhaps saving hundreds of millions of lives.  The urge to control and suppress them as tobacco products should be resisted and instead regulation that is fit for purpose and designed to realise the potential should be championed by WHO. 

7. Do e-cigarette help people quit smoking?

Yes, it looks like it, and in the real world too – not just in the artificial world of clinical trials. In fact they appear to be more successful than established smoking cessation products like NRT.  A recent study found that people were 60% more likely to succeed using e-cigarettes.

People attempting to quit smoking without professional help are approximately 60% more likely to report succeeding if they use e-cigarettes than if they use willpower alone or over-the-counter nicotine replacement therapies such as patches or gum, reveals new research published in Addiction.
Brown, Beard, Kotz, Michie & West, ‘Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study’Addiction, May 2014.

ASH’s 2014 survey showed that about a third of users were now ex-smokers – 700,000 in the UK or about 7% of the smoking population – implying that many people are successfully quitting.

+ An estimated 2.1 million adults in Great Britain currently use electronic cigarettes.
+ About one third of users are ex-smokers and two-thirds are current smokers.
+ The main reason given by current smokers for using the products is to reduce the amount they smoke while ex-smokers report using electronic cigarettes to help them stop smoking.

People should also take the trouble to listen to the thousands of accounts of the experiences of people switching. These are often dismissed as anecdote – but you hear the same message over and over again.  Take this for example:

I smoked for 45 years and tried every NRT product available, none of them worked. I continued to smoke even though my health was getting worse, resulting in COPD and using oxygen daily. September 2011 I discovered e-cigarettes and they worked. It was like someone handed me a miracle. In less than a week I stopped using regular cigarettes. I haven’t had a tobacco cigarette since. I wish the MP’s and MEP’s would understand how much e-cigarettes have helped thousands of people just like me.

See many more testimonies like this in my posting: Where is the empathy, where is the humility?

8. Do people who switch continue vaping or move on to quit altogether?

We will have to wait longer for the data to come in on that, given that e-cigarettes are relatively new to most users.  The better question is whether it matters.  If the health risk of using a vapour product is very much lower than smoking, then the important transition is from smoking to not smoking.  Whether that means continued vaping or complete cessation of nicotine is a second order concern. One of the advantages of vaping is that it is a much easier transition than quitting completely: it is easier to do in the first place because it does not involve overcoming nicotine dependence and so withdrawal and craving are greatly reduced.  It may also mean relapse is less likely.

9. The Minister of Health is not convinced of the safety of e-cigarettes – what now?

This is probably literally true: he is not convinced. But that doesn’t mean he has made a competent assessment or is applying the same standards he would apply to other risks in this field. What the minister needs to say is what would convince him. Nothing is ever entirely safe – we usually judge whether risks are tolerable, given the benefits and demand for the product.  By way of comparison, I wonder if he is convinced of the safety of, say, Varenicline ( a stop smoking medical treatment marketed as Champix or Chantix)? I am not saying people shouldn’t use it by the way, just that its safety has been judged on a risk-benefit basis. You certainly couldn’t call it ‘safe’.

The list of known-knowns, the noted side-effects, is long and unpleasant:

And the list of serious concerns (the known unknowns) is quite troubling and these concerns remain unresolved as these papers from the US Food and Drug Administration show:

The health minister needs to examine his conscience and decide if all his negativity, doubts and worries are in fact discouraging people who smoke from trying an e-cigarette, and so supporting the cause of continued cigarette use. It is possible he has made himself one of the most powerful friends and allies of the tobacco industry, though without actually realising it. He led the European Council push to have e-cigarettes regulated as medicines, a move which would have virtually destroyed the existing industry and handed what remains to Big Tobacco.  In my view health ministers, lead by the James Reilly of Ireland displayed a particularly trite and cynical form of negligence. See: Negligence in tobacco policy.  The same criticism can be levelled at the rest of the public health establishment – exceedingly complacent with hugely exaggerated concerns about minor or hypothetical risks and apparent indifference to huge potential for health gains.

10. A health organisation has said ‘we just don’t know what’s in them’ – do we really know so little?

They’ve been on the market since 2008, and its now 2014. What have they been doing all this time? In fact there is quite a lot of evidence about these products (see PubMed), if they bothered to look and to have an open mind. I recommend this review: A fresh look at harm reduction the case for the electronic cigarette, Polosa et al 2013.  Critics should start be reading the Igor Burstyn review: peering through the mist – and I would advise anyone encountering this argument by ignorance to ask what they think of Burstyn’s review.  None of this is to say that some regulation isn’t justified to create good basic standards and to improve consumer confidence. The trouble is that many of those saying they don’t know, actually don’t want to know. They want ignorance to be the basis of fear and fear to be the basis of coercive policies.

11. Shouldn’t people who want to quit smoking use licensed smoking cessation medicines like NRT?

NRT may help some people, but what if other people don’t want to quit nicotine or choose not to use NRT or other medications? E-cigarette use isn’t about quitting it’s about continuing – in this case continuing to use the legal recreational drug nicotine – in a way that is very much less hazardous to health.  The correct comparator is smoking, not NRT. We should remember that snus has huge benefits in Sweden without ever being approved or highly regulated by anyone – it works so well because it substitutes for smoking. Regulating these products as medicines would kill them off – effectively raising costs, crushing innovation, killing the buzz and dramatically reducing the range of products available.  The main effect of medicine regulation would be to destroy most of the industry, leaving what’s left to the deep pockets of the tobacco industry. We also have evidence that people using e-cigarettes have more success at quitting than people using NRT – so why would an ethically sound health professional recommend the less effective option?

12. Shouldn’t we just ban vaping indoors as we have done with smoking?

No, unless and until there is evidence of harm, it is not appropriate to use the coercive powers of the law. If someone want to open a bar that welcomes vapers then the only reason for the law to stop them is if someone else is harmed – or at least there is no prospect of a material risk.  The law shouldn’t be used to regulate consumer choice, good taste, aromas, aesthetics. The idea that it can hide vaping from view is absurd – people will be outside a building rather than inside.  Owners and operators should make the decisions as they are best placed to weigh different social, economic and wellbeing issues.  Note that allowing vaping can have health benefits: it may encourage smokers to switch and prevent vapers relapsing to smoking. It adds to the value proposition of e-cigarettes, relative to smoking.

13. E-cigarette advertising is targeted at children and should be banned

No it isn’t – and it is a huge evidence-free defamatory accusation to assert that manufacturers are targeting kids. No manufacturer is targeting kids (and if they are they have been a miserable failure, given how few kids vape!) for two main reasons: (1) they’d be suicidally stupid to try it; (2) they have absolutely no need to incur the vast reputational risks involved – the world tobacco market is $700-800 billion, vapour products so far have less than 1% of that.  Their value proposition is strongest for existing smokers who want a change or have growing concerns about their own smoking. Tobacco advertising is banned in the EU because smoking kills over 500,000 people annually in the EU – no such justification can be made for e-cigarettes.  In fact, it is much more likely that e-cigarettes will have a negative death toll – a protective effect on smokers. Advertising is critical in the e-cigarette world and much of it is powerful persuasion against smoking: it is necessary to communicate with smokers; to incentivise, communicate and reward innovation; to build trusted brands; to create buzz… all of this helps to bring smokers over to vaping.

It is possible that some non-smokers may be persuaded to vape or ex-smokers decide to take it up – it would be foolish to claim this is impossible. That creates very little health risk in itself and has to be set against potential huge health benefits to smokers who switch. There are no real absolutes – it’s a matter of being proportionate about risks and benefits.

14. Nicotine is a powerful poison and needs to be strictly controlled or outlawed

Huge hype has been generated by the New York Times, which discovered a ‘surge’ in nicotine related poisoning events:

… the number of cases linked to e-liquids jumped to 1,351 in 2013, a 300 percent increase from 2012, and the number is on pace to double this year, according to information from the National Poison Data System. (NYT 23 March 2014)

Yes, that sounds very bad…  but it turns out this is a rapid rise in a small number compared to other poisoning calls in the US:

Nicotine related calls compared to other poisons

Nicotine related calls compared to other poisons

Source: 2012 Annual Report of the American Association of Poison Control Centers ’ National Poison Data System (NPDS): 30th Annual Report

Here’s the truth:

15. The tobacco industry is involved and they will want to force smokers to keep smoking

The appalling history of Big Tobacco should give everyone concern – but not to the point of blindness and paranoia. These companies are interested in taking market share from each other in the combined profit from tobacco and e-cigarettes. They would happily get it all from e-cigarettes if they could. To defend their total business the tobacco companies will need to develop top quality products that appeal to smokers, or else someone else will.  Their incentives are not to defend smoking but to retain their customers – if that involves them stopping smoking, then so be it. More on this in my reply to an article on the tobacco industry.  Jonathan Fell, the former tobacco analyst at Merrill Lynch, Morgan Stanley and Deutchse Bank says in a debate with prominent anti-e-cigarette activist:

The idea of tobacco companies selling lower-risk products might be anathema to some, but what else could a responsible management and board do? It’s been an effective public health strategy to demonise the tobacco industry in the past, but many tobacco control advocates seem be in danger of believing their own propaganda on this point. Tobacco industry boards and managements are much like the boards and managements of any other consumer business. A product which is potentially beneficial when sold by one company doesn’t become a bad product just because it’s sold by someone you don’t like.

If people don’t like Big Tobacco, they don’t have to buy from them. The only institution that could allow them to abuse the market is a regulator – by raising barriers to entry that only they can match and so giving them control. Something they seem determined to do in many jurisdictions.

16. We are going to clamp down on e-cigarettes in hospitals

These are problems for the health establishment, not problems with e-cigarettes.  E-cigarettes are not medicines and as long as HSE talks about them as though they are, they are missing the point.  They need to think more carefully of the welfare of people in hospital, who may be there precisely because they smoke. It could be a great opportunity to convert them to something much less dangerous and so make an important preventative intervention as well as help them feel better while in hospital.  There may be a case to allow vaping on health and welfare grounds and to start hardened smokers (yes, the ones you tend to find in hospital) on a journey to stopping smoking, via vaping.  There is definitely no case to be even more prohibitive than for smoking.

17. A doctor is saying nicotine is as addictive as crack cocaine, and that tobacco is just like a syringe for nicotine

This doctor has no basis for the comparison with crack cocaine.  Crack is the free base form of cocaine.  Even for cocaine in its non-free based form the claim was debunked more than 20 years ago.

…we consider several lines of evidence, including patterns of mortality, physical dependence potential, and pharmacologic addiction liability measures. Within each line of evidence, we compare nicotine with cocaine. We conclude that on the current evidence nicotine cannot be considered more addicting than cocaine. Both are highly addicting drugs for which patterns of use and the development of dependence are strongly influenced by factors such as availability, price, social pressures, and regulations, as well as certain pharmacologic characteristics. (Henningfield et al 1991 Is nicotine more addictive than cocaine?)

Nicotine in itself is not that addictive, it matters how fast nicotine is delivered and whether there are sensory and behavioural reinforcements.  Smoking may also introduce other psychoactive substances (MAOIs) alongside nicotine.  It is more accurate to say that smoking is addictive.  One of the foremost experts in nicotine, Karl Fagerström, explains it as follows on this blog 9 May 2014 entry:

As much as there is a continuum of harm from nicotine containing products there is also a continuum of dependence. Dependence is of course also part of the total harm. We know of no nicotine patch use among people who have never smoked that has resulted into compulsive use i.e. dependence. There are cases, although only a few, of gum use by never smokers that has resulted in dependence  or transition to tobacco use. Thus, nicotine products, without involvement of tobacco, seem to have a dependence potential close to caffeinated drinks.

[…]

I would expect e-cigarettes to be generally less addictive than tobacco cigarettes because they mostly deliver nicotine more slowly and they do not deliver the other psychoactive chemicals. I would expect them to be more addictive than other pure nicotine products because they involve a repetitive activity and sensations that have been linked to smoking.

Even so, the question is not that relevant.  The most important point for a doctor is that nicotine can be addictive or in smoked form very addictive, but in itself, isn’t that harmful.  It doesn’t cause intoxication or induce strong tolerance, requiring ever larger doses. In the form of smoking it is very harmful to health in the long run. So if people are using nicotine – a legal widely available recreational drug – then they would be far better using it from an e-cigarette than by smoking tobacco cigarettes.

Other doctors are more sensible:

And Dr Chris Steele discusses e-cigarette on ITV’s breakfast programme – sound advice:


18. The long term effects of inhaling e-cigarettes are not known. Should they not be restricted until it is known they are safe for continuous use?

It is a statement of the obvious to say that the long term effects are not known – they can’t be known with certainty until the long term has passed and data is available to study. The seminal study on smoking and health is called: Mortality in relation to smoking: 50 years observations on male British doctors because it takes that long to build up a comprehensive picture. E-cigarettes have been in use for only a few years and their use is evolving all the time – we don’t even know yet if people will use them over several decades, as with smoking.  But this lack of knowledge about the future is common in policy-making.  The approach used is rely on what we do know, which is far from nothing – rather than complaining that we don’t know everything.  So opponents of e-cigarettes talk as though they have just arrived from Mars (the e-cigs), but in fact we know quite a lot.   From what we do know, we can make a reasonable risk assessment.  So far, we can say:

  • We are certain that there is no combustion. This is the most important difference and matters a lot because it is products of combustion do the a lot of the damage in cigarette smoke
  • We can look for toxic substances that may cause serious disease over time – we find these are either not present at all, or present in very low concentrations compared to cigarette smoke or workplace limits
  • No serious acute effects have emerged (you would know about it if they had!) and most users report considerable improvement in short term health and wellbeing
  • This is not to say there are no grounds for concern – for example we might be carefully study two potential sources of risk: (1) breakdown products arising from running at high temperatures; (2) the complex chemistry of natural flavourings. However, there is so far no credible theory that gives cause for alarm about these.

However, we do know with certainty that smoking is harmful. There is a great danger that in restricting e-cigarettes because of uncertainty, we will end up with more smoking, which are certain is harmful. So the so called precautionary principle (discussed here) has to look not only at the risk of e-cigarette use but also at the risk of restrictions on e-cigarette use and the potential to cause more smoking as a result – it isn’t just a safe one way cautious bet.  So the right way to handle the long term uncertainty is:

  • keep studying the physics and chemistry of e-cigarettes and liquids
  • develop and test theories by which harm may be caused
  • keep up epidemiological surveys on the user population
  • set standards for products that make sure they are reasonably safe and high quality
  • be flexible enough to intervene and change policy to introduce restrictions if problems emerge
  • recognise that any problems may be confined to narrow circumstances (particular flavours, or devices) so target restrictive regulation on them – not the whole category
  • remember that restrictions on e-cigarettes may cause more smoking and thereby do more harm than good.

19. E-cigarettes should be regulated as medicines to guarantee safety, quality and efficacy

This is about the worst idea for regulating e-cigarettes that anyone has ever had.  The basic problem is that this regulatory framework is there to control quality, safety and efficacy of medicines.  E-cigarettes are not medicines, but alternative ways of taking the legal and widely used recreational drug nicotine with many superior features compared to smoking. The main problems that will arise include:

  • Consumer choice severely limited. A dramatic contraction in the number and range of products on the market – the high costs and burdens of applying will not be worthwhile for most products
  • Consumer priorities ignored. No sign of any consumer demand for it – the only people who want it are health activists.   Consumers want fun, frivolous, appealing products that are safe enough.
  • Supply chain disrupted or destroyed. Major impacts on the supply chain, that would need to upgrade to pharmaceutical standards of manufacturing
  • More effective products barred. Tendency to commodify the market – yet the most successful products from a health perspective are the vapour, mods and tank type products – exactly the ones that fare worst under this system
  • Brake on innovation. Slower and less imaginative innovation – with high costs and burden of achieving approvals, companies will be cautious
  • Deadweight costs.  Higher  compliance costs, unnecessary restrictions, heavy burdens will raise costs, constrain product design and divert management focus away from consumer to the regulator
  • Banality. Tendency to eliminate buzz and excitement and become boring and bland – see NRT packaging and marketing for example
  • Recreate tobacco oligopoly.  Creates barriers to entry, reduces competition and plays directly into the hands of the biggest companies
  • Illegal. If forced on companies, it would be unlawful – e-cigarettes do not legally fall under the definition of a medicine as repeated judgements in Europe and US have shown

I could go on… and in fact have – 10 reasons not to regulate e-cigarettes as medicines and The case for regulating e-cigarettes as medicines: a line by line examination

20. What if the critics of e-cigarettes are wrong?

This is the question they have to answer. They are in positions that command trust and that people look to for advice.  If they are making these arguments with no evidence and poor judgements where there is uncertainty they may be inadvertently increasing smoking and protecting the cigarette business. A group of 53 scientists recently wrote to the WHO suggesting ten principles (see my reader’s guide to this letter for more).  The third highlights this risk:

3. On a precautionary basis, regulators should avoid support for measures that could have the perverse effect of prolonging cigarette consumption. Policies that are excessively restrictive or burdensome on lower risk products can have the unintended consequence of protecting cigarettes from competition from less hazardous alternatives, and cause harm as a result. Every policy related to low risk, non-combustible nicotine products should be assessed for this risk.

21. “E-cigarettes contain [rat poison][weed killer][anti-freeze][carcinogens][insert scary sounding chemical here]”

We often hear claims that e-cigarettes contain something nasty and scary sounding.  Actually no they don’t – other than as a propaganda.  These claims are generally based on two types of error (sometime both):

1. Chemical illiteracy – for example confusing propylene glycol (e-cigarette vapour base liquid) with ethylene glycol (anti-freeze).

2. Confusion of hazard and risk – nicotine is a natural pesticide, but is not poisonous in e-cigarettes (or cigarettes). The key concept to understand is that the dose makes the poison.  Whether a chemical is hazardous is a property of the chemical.  Whether it poses a risk to health depends on the hazard and the exposure.  We are exposed to hazardous chemical all the time – in all cooked food, ambient air, drinking water.  Take coffee.  It is literally the case that we do not know what is in each cup – the roasting process is chemically uncontrolled and creates many de novo chemicals, including numerous carcinogens – see this statement from one of the pioneers in the field:

Over a thousand chemicals have been reported in roasted coffee: more than half of those tested (19/28) are rodent carcinogens. There are more rodent carcinogens in a single cup of coffee than potentially carcinogenic pesticide residues in the average American diet in a year, and there are still a thousand chemicals left to test in roasted coffee.
The causes and prevention of cancer: the role of environment (Ames BN, Gold LS 1998).

22. The ultimate public health aim is to remove reliance on nicotine entirely

That is the ultimate aim of some campaigners is the complete cessation of nicotine use (see this article).  There are four objections to this reasoning:

1. Libertarian. Nicotine is a recreational drug that many people like using and does no harm to others through toxicity or intoxication, nor does it impose costs through the health care system. It is the individual, not the public health authorities, that should determine what the ‘ultimate aim’ is for them personally.

2. Utilitarian. Nicotine is a functional legal recreational drug that people like using, or in the case of many ex-smokers miss using.  If nicotine use is no longer conflated with the significant harm caused by smoking then what’s the objection? Over time we will come to be seen as more like having a strong coffee in the morning or a glass of wine with dinner. We do not generally strive for zero drug use in society, and drug use is a feature of human society going back millennia.

3. Pragmatic. The switch from smoking to vaping is the crucial transition for health and harm reduction purposes.  The additional step from vaping to abstinence provides little additional health benefit, but comes with welfare costs including withdrawal and craving and extra risks, including relapse to smoking.  In some ways, vaping may be a form of ‘inoculation’ against relapse to smoking.

4. Professional.  Public money is spent on public health through the NHS, local authorities and on supportive bodies like ASH.  Public spending should meet tests of ‘value for money’ (outcomes that justify expenditure) and ‘regularity’ (some sort of authority for taking action [see bible of public spending: Managing Public Money]. There is no basis against these criteria for spending public funds on abstinence objective – and it is why NHS Stop Smoking Services should not consume public funds helping people to quit vaping rather than smoking.  That is down to the individual.

If publicly funded ‘public health’ wants to become a temperance movement it needs to show that abstinence leads to harm reduction that provides value for money consistent with norms for public spending. If it is drawing on charitable funds (eg. from cancer or heart charities) it needs to ensure that abstinence – rather than harm through cancer or heart disease – is consistent with the relevant charitable objectives.

23. Those flavours are there to attract children

The wide range of flavours are there to meet demands from adult smokers.  No-tobacco flavours are important to ex-smokers in sustaining a long term migration away from tobacco use, and for preventing relapse to smoking.  They form an interesting part of the value proposition to smokers: personalisation, experimentation, connoisseurship and fun. A the E-cigarette forum survey of vapers showed flavours in widespread use by adults, with fruit flavours dominating. 65% of vapers (self-selected from this site’s large base of engaged users) report that flavours have been important to them in the transition from smoking.

Vaping-data-flavors

It is also asserted without evidence that adolescents prefer ‘childish’ flavours. Why would they? Part of the purpose of using an e-cigarette is to emulate adult behaviours – it cannot simply be assumed that they will adopt flavours that reinforce childishness. A further problem with many of the assertions made about flavours regards intent – the idea that e-cigarette manufacturers are ‘targeting kids’  is offered without any substantiation, yet it is a serious allegation often made and far too lightly. Perhaps one day a defamed e-cigarette maker will go to court to demand some evidence to back this lazy smear.

See article by Jacob Sullum.

Appendix. How well is Ireland doing on tobacco and health?

Badly.  Very badly. 38th out of 41 badly. Ireland’s public health establishment and government talks the talk with quite some swagger, and even asserts that it will be smoke free by 2025.  In fact in 41 countries surveyed by the OECD it ranked 38th (see graphic at the end of this post). So Irish vapers should not be taking any criticisms from them: they’ve basically failed in their own self-declared mission and should be listening, not lecturing, right now. Ireland has one of the highest smoking prevalence rates and one of lowest rates of decline in smoking in the OECD between 2000 and 2011.  It is common to claim that traditional tobacco control is just on the cusp of a great victory, and that e-cigarettes are putting all that at risk. Not so really.

OECD smoking data 2013

Ireland at the bottom of the league

This failure has not caused much pause for reflection in the Irish public health establishment, and in fact Ireland is applauded in tobacco control for having the best policies (second only to the UK) – see the European Cancer Leagues tobacco control score card.

Tobacco control policy score card: measures activity not results

So if Ireland ranks high in policy activity but low in smoking results, what does that tell us about: (1) the quality of the policies; (2) the values and purpose of the tobacco control community.

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77 comments to Arguing about e-cigarettes – a Q&A

  • An outstanding summation of the overall position, Clive. Deeply impressed with this and plan on sharing it far and wide. :)

  • Guy Eaton

    Absolutely excellent!

  • Rotax

    May I translate this blog entry into Finnish language and publish it given credits to you, of course?

  • Thanks!

    For the appendix, it might be interresting to include what absurd criteria are used to reach those deranged scores: [C&P from their rank(ing) “scale” page]

    1. price increases through higher taxes on cigarettes and other tobacco products;

    2. bans/restrictions on smoking in public and work places;

    3. better consumer information, including public information campaigns, media coverage, and publicising research findings;

    4. comprehensive bans on the advertising and promotion of all tobacco products, logos and brand names;

    5. large, direct health warning labels on cigarette boxes and other tobacco products; and

    6. treatment to help dependent smokers stop, including increased access to medications.

    Anybody with have a brain and a pinch of common sense would put smoking prevalence as the most important factor. And it isn’t even on the list!

    And what exactly is there?
    – How successful were they fleecing smokers and the rest of the tax payers?
    – How much nannying could they bully through into restrictive laws?
    – How may (repeat) customers do their public front funnel through the works (on tax payers money)

    And at the bottom of it all is: How much filthy lucre did they make and spend to increase their political influence?

    Health?
    WHO cares about health!

    • Clive Bates

      It is quite bizarre that the authors of this scale have never taken the obvious step of looking for a correlation between activity and outcomes: that is the relationship between tobacco control measures and smoking prevalence or rate of change of smoking prevalence. Well, we know why… the correlation barely exists.

  • Adrian Hey

    Though more sensible than most I don’t agree with Dr Steele’s assertion about the “guaranteed purity, quality and safety” of whatever’s left on the market in 2016.

    As I understand it the TPD requirements are so draconian that it’s far from clear that any legal e-cig products will be available. As for the alleged guarantee of purity, quality and safety I think the only new guarantee the TPD provides that we don’t a already have is guarantee of a minimum 10 fold price hike in an industry that is now effectively “owned” by the deep pocketed tobacco and pharmaceuticals giants. We can kiss goodbye to all those mom & pop vape gear and e-liquid suppliers that currently serve us so well.

    • Adrian Hey

      Or put simply in 2016 the best case scenario is that vaping will be at least as expensive as smoking already is. Worst case scenario is that vaping won’t even be an option as there are no legal products on the market at all.

    • Clive Bates

      Adrian… I think that some basic standards are important and that consumers should expect them The assaults from obsessive regulators have been so extreme that they have united the industry and consumers against them. But consumers should not want rogues or dodgy products on the market. My argument has been that what Chris Steele is asking for is simple and does not involve (mis)classification of the products as medicines or the arbitrary bollocks-fest that emerged from the secretive negotiations of the TPD.

  • This is excellent Clive – thanks

    one suggestion: on point 2: Does nicotine cause cancer or other health effects

    – you only address cancer – and dont mention other health efefcts. i think kit would be good to at least mention heart disease risk as this is the other major public health concern with smoking.

    • Clive Bates

      Hi Steve – added new text above. There are minor side effects, some cardio effects like caffeine and some concerns about foetal development. There are also possible benefits and the obvious welfare gain of avoiding withdrawal and craving.

  • Bill Godshall

    Another excellent analysis and summation of the scientific evidence (with great graphics) on e-cigs beneficial impact on public health, and refutation of the many false and misleading fear mongering claims by intolerant, unethical and inhumane anti-tobacco/nicotine extremists.

    What I find truly amazing (and shocking) is that the vast majority of these harm reduction opponents are public health officials and health and medical groups (that have been heavily lobbied and funded by Big Pharma to promote/protect NRT and Chantix markets).

    Their egregious actions to prevent smokers from quitting and to threaten the lives of smokers and vapers (under the deceitful guise of protecting children and public health) should treated similarly as occurred with Andrew Wakefield.

  • Dave J

    One kind of sub-subject I would like to know about my self is the flavorings and there affects. I know many companies have dropped Diacetyl use after the “popcorn lung” issue arose. However, it turns out that a frightening amount of those flavors stated to be Diacetyl free are not in fact free of diacetyl. The main reasons I have found for this are these (1) No diacetyl is added there for it is diacetyl free. Wrong, diacetyl is a naturally occurring chemical in many fruit, dairy, and bean items, such as strawberry, cream, vanilla. (2) Diacetyl is not present, but one of the other chemicals in the diacetyl family are. While in this case the liquid tests free from diacetyl, the act of vaping, passing the liquid over the heated coil, causes a chemical reaction in these “family members” with an end result of diacetyl being found in the vapor. While I agree the e-cig is low on concern for causing cancer, the risks from diacetyl are not classified as a cancer, only as a lung disease. I do vape and have quit smoking using an e-cig, so don’t think I’m bashing it. However, after looking into DIY eliquid to save some money, I saw little concern over what could be more harmful than tobacco, and in every flavor eliquid I looked into making. I now DIY but use only non-flavored eliquid.

    • Adrian Hey

      Yep. I mix my own and rarely add any flavouring at all. I find completely unflavoured nicotine/pg/vg mix to be quite pleasant. I agree that whilst e-cigs are definitely unfairly demonised, more work research is need on what is used in flavourings. (Not a ban, just research!).

      Some of my attempts at flavoured concoctions have left me coughing and wheezing far worse than 40 Rothmans/day ever did. Chocolate flavourings seem to be a problem for me, but perhaps not all such, and perhaps not everyone is affected the same way.

      So most of the time I just don’t bother. If I ever try flavouring again I think I’ll test each individual flavouring first before I mix any flavours (once mixed it’s hard identify what it is that’s causing any adverse reaction you may be suffering).

    • Clive Bates

      Dave – good question, but I’ll have to come back to this.

  • vapingpoint

    This is very excellent material, worth sharing everywhere.

    My rebellious side – the side that kept me smoking in fury at the sanctimonious, interfering of tobacco prohibitionists that ruined my life and all the lives of smokers my age, sees that their years of work and trillions of pounds squandered world wide, have done very little to ACTUALLY reduce smoking. I am really looking forward to the time when the use of recreational nicotine is accepted as a valid pleasure.

    Smoking has not been denormalised. Almost a quarter of the population(UK)do it – probably more – in truth as not everyone admits to the shame of it. It is even legal – a legal pleasure. Now we have a truly amazing substitute for it, the future should be to dump the tobacco control industry as an exorbitantly expensive failure and let consumers make the switch to devices that successfully do the job in smoking substitution.

    Smoking rebels might feel free to convert to vaping when released from imposed anti smoking paranoia.

    I smoked for 50 years. Fortunately I am well, despite predictions of my early death.

    I have vaped now for almost three years. My last cigarette was in 2012. Sometimes the only reason I wish I still smoked is that I would be in a better position to defend smokers from the evil machinations of prohibitionists. I vape because I prefer it to smoking.

    But the current behaviour of the anti smoking brainwashed against electronic cigarettes, confirms my angry smoker opinion that the anti smoking industry really does need to implode. Our world would be a much better place without the expense and misery they have promoted by their existence and the future harm they seem determined to cause.

    I salute you in your defense of vaping and vapers. Totally selfishly, I would like to vape in comfort for the rest of my life without interference from tobacco control AGAIN. So I really do wish you the very, very best in your efforts on our behalf. And sincerely thank you.

    • Mark Bolton

      Beg to differ. I am about as much of an anti smoking Nazi goosestepper as you will find. I would love it if vaping became popular – even better – took over all together. It doesn’t stink. It doesn’t make people I care about sick. Unlike #@%$# baccy!!

  • Chris Price

    -DaveJ
    You might be interested to know that no proposed regulations in any country specifically address the question of how to control refill liquid quality – the only thing that does need regulating. All proposed regulations are instead designed to restrict or remove ecigs from the market.

    The purpose of regulations in the EU is to protect government tobacco tax revenues and pharmaceutical industry income from treating smoking-related disease; and in the USA likewise, plus protection of State MSA payments, and city and State tax revenues. The MSA payments have already started to slide, way ahead of the estimated year this would happen; and this is a disastrous event for State economies. We already see the effect: the State’s Attorneys General working as hard as possible to protect cigarette sales.

    This should be a clear enough pointer to exactly how those in power regard public health: it is irrelevant. Ireland is a great example of how useless tobacco control is (and in my opinion fraudulent). Instead, Sweden will have a male smoking prevalence of 5% by 2016, and a proportionate level of smoking-related death and disease. Beat that.

    • ” no proposed regulations in any country specifically address the question of how to control refill liquid quality – the only thing that does need regulating.”

      Excellent point Chris, and very true. Possible addendum: I could see *some* degree of regulation on the safety of some of the mechanical devices. Their problems are being overstated of course by the Antivapers, but with so many small, independent manufacturers there are bound to eventually be real problems if there’s no oversight at all. The trick is getting *REASONABLE* oversight: not the $500,000.00 thousand-page 7-year-studies sort of nonsense that groups like the FDA seem to be pushing — which seem to really be designed just to ensure that only the big cigarette manufacturers can afford the tab (and maybe eventually be forced to pony up replacement money for the MSA funds that are lost.)

      – MJM

  • Kurtis Sunday

    Dr Chris Steele’s common sense was refreshing.

  • Joe Avsenik

    An absolutely stellar article which needs to be circulated to every government agency and official even remotely considering the prospect of onerously regulating or banning e-cigarettes.

  • Tim Triple

    Clive,

    A further question: ‘The long term effects of inhaling e-cigarettes are not known. Should they not be restricted until it is known they are safe for continuous use?

    I have a feeling this may get raised more as the other common objections have been increasingly shot down in flames.

    • Dave J

      I’ve heard this argument before, the way I answer it is by untimely asking another question. Let’s take 2 different thing and compare them, Smoking and food. Smoking is a known “bad” and food is food, it has always been safe to eat most things through out history. Fast forward to this time in history. We have e-cigs which “should be band because we do not know if they are safe” and GMO food which is FDA approved as “it have never been proven to be harmful”. Do you see the double standard? Which is it, we ban something till proven safe or we use till proven bad?

  • Lorien

    Quite aside from the fantastic & comprehensive summary you have written here, I honestly think that the closing line is the most relevant. All these arguments are only having to be made against the apparent ignorance, as this is the mindset of the people creating issues where there are none. That is what’s most troubling in all this, it stopped being about helping smokers & preventing uptake a long time ago. It’s now a Crusade.

  • Junican

    @ Chris Price.

    Can I first say that I much admire the clear sincerity of everyone who has commented here – very refreshing when compared with the charlatans who currently ‘own’ the Tobacco Control Industry. Also, may I assure Chris that anything that I say in the sequel is in no way intended to be critical.

    Not a lot of people know this.

    In the final report from Doll about the Doctors Study, there is a table. What this table shows is this:

    85% of smokers die from ‘tobacco related diseases’. That is terrible, is it not? But it might surprise you to learn that 84% of non-smokers also die from the self-same ‘tobacco related diseases’. (I can supply the exact numbers if you wish) What this means is that not smoking ’causes’ tobacco related diseases almost as much as smoking does. The difference between the two groups is not ’cause’, it is ‘when’. Thus, one might correct the statement, “Smoking causes the death of half its practitioners” to continue with the clause “… and not smoking causes the death of a little less than half its practitioners” Better still, you could say that: “Smoking causes the death of 100% of smokers and not smoking causes the death of some 95% of non-smokers”

    You mat sneer, but before you do, read the final report of the Doctors Study.

  • Chris Price

    Hi J,

    We should probably discuss this elsewhere? Can I suggest the THR FB page?

  • Erik Befrits

    For the sake of future tobacco harm reduction work in LMIC countries and other settings where e-cig simply aren’t feasible or practical: would it be reasonable to produce a THR nomenclature that includes all current and future THR products with sufficient risk reduction properties compared to conventional smoking? Excellent piece, as usual.

  • TheDan

    Impressed. Thank you so much for putting it all in one place …

  • […] was contacted by a vaping enthusiast from Ireland, asking for assistance in dealing with the arguments they are facing. The Irish public health establishment appears to have a death wish against smokers that is even more vengeful than in most other European countries. So in an act of solidarity I dashed off some answers to his questions and decided to turn the results into a blog.  […]

  • Another superb piece of work, Clive. I salute you!

    It might interest your readers to know that ECITA is currently working with a Public Analyst on a protocol for emissions testing, as well as honing our existing eliquid testing protocol. Alongside this, we are also working with the British Standards Institute to produce some recognised standards for a Code of Practice for this sector, as well as Testing Methodologies. We share consumers’ concerns about those ‘unknown risks’, and recognise the need to improve the industry standards.

    We have always recognised the need for robust, proportionate and appropriate sector-specific regulation. Indeed, this is why ECITA was established in the first place.

    The dogs’ breakfast that is the TPD will be legally challenged, and I believe this challenge will be successful. I believe we shall continue to have good regulation for these products, with additional requirements specific to and directly appropriate (and proportionate) for these unique, revolutionary products.

    Keep up the good work, Clive.

  • […] I was contacted by a vaping enthusiast from Ireland, asking for assistance in dealing with the arguments they are facing. The Irish public health establishment appears to have a death wish against …  […]

  • john

    Really good summary of the whole case! Should be circulated widely!
    Small quibble, I thought that e-cigs had been in use in China for a bit longer than since 2008?

    • Clive Bates

      John – they emerged as early as 2004, but not in any meaningful quantities until 2008 or later. In fact it would be hard to study them until about 2010.

      • Anonymous

        Thanks. , re flavorings I think that regularly changing favors , should reduce the risk. interesting side issue is that from what a friend tells me, flavors and aromas are not that we’ll researched , there are a extrordindary number of them, and many combiniations are , like ‘Cokes’ formulae are commercial trade secrets.

        • Guy Eaton

          Many liquids now made to a medicinal purity…almost having nothing in them even compared to the air you breath (particularly polluted air)!!!! Unlikely these would be significantly harmful even in the long term. Again the relativism argument pops up – I think you can be 100% sure less harmful than cigarettes at any rate.
          The interesting aspect is I don’t think smokers want ECs to be 100% save they just want them safer…it is only the people who don’t use them who want them to be as safe as a apple – particularly because the want every excuse to ban or restrict them and because they are quite simply stupid. I think even if ECs offered the same risk as hay-fever tablets it would be enough to ban them and have 10 articles from the Daily Mail stating that they are far worse for you than smoking real cigarettes. That is ECs have to reach safey standard higher than most other products to be accepted – I wonder why?! This is particularly strange considering the alternative is the most deadly drug ever invented!

  • **VERY** well done! I’d like to add two points:

    1) An expansion of your #14: The “powerful neurotoxin” description of nicotine has also been used by the “thirdhand smoke” nuts in trying to frighten innocent people. And the 1,315 “cases” from the National Poison Control Center are almost certainly mainly cases of parents WORRYING because of all the hype rather than actual poisonings. You can see how far the Antivapers are reaching when they start pulling up single anecdotal examples for e-liquids while ordinary aspirin and cosmetics have cases numbering literally in the hundreds of thousands — despite there being virtually no “scare propaganda” flooding the public consciousness about “deadly lipsticks” etc.

    2) You can see an analysis of how the anti-vaping studies twist the science with their claims at http://bit.ly/FDAstudy using the same sort of “This is a chemical used to preserve dead bodies.” or “This is a chemical in antifreeze.” or “This is a chemical in rat poison.” games they’ve played for so long with secondhand tobacco smoke.

    Basically, the Antivapers are just “repurposed” Antismokers (mainly from the “Moralist,” “Controller,” and “Greedy” categories outlined in Dissecting Antismokers’ Brains.) They’re using the same tricks, language and propaganda techniques that proved so successful for them in the fight against smoking. Vapers need to learn the lessons that those of us in the more generalized Free Choice movement often learned too late in our fights and avoid making the same mistakes.

    – MJM

    • Guy Eaton

      Out of interest funnily enough there are benefits of nicotine neurologically that have been proven scientifically similar to caffeine (improves memory and cognitive functions). It also speeds up your metabolic rate significantly. These factors are never mentioned (or very rarely). Any real danger from ECs actually really comes from poorly made hardware (i.e. fires, etc). There could be some minor issues relating to purity although again as nothing compared to smoking cigarettes. The problem is there is a misplaced obsession with nicotine and purity particularly in Europe which may divert attention from any real significant dangers. Just and observation! This is why propaganda and ‘gut feelings’ have not place in saving lives, they completely divert attention away for anything meaningful or helpful.

    • Clive Bates

      Thanks Michael – these are good suggestions. I’ve included an update to q14 and a new q21.

      • Regarding q21.2 it might be funny to point the scaremongers to homoeopathy:

        Their basic principle is to take either the originally harmuful substance or something that in high doses produces similar symptoms and drastically dilute it. With the magnitude of dilution its “potency” to heal is supposed to increase.

        How is it possible that the same health nuts who yell about the tiniest detectable traces of somthing potentially (in much larger doses) harmful in ecigs vapour often embrace and praise homoeopathy?

    • I find it rather revealing that they have to resort to presenting “anecdotals” instead of confirmed case numbers. I totally agree with you. I guess a statistical analysis would show a strong correlation of these calls with the amount of scaremongering media coverage. It smells a lot like a self fulfilling prophecy.
      Of course there also is an obvious correlation between the growing number of users and the number of calls to be expected.

      Even more revealing: The director of the same CDC dismisses thousands of (unpaid) statements of happy and healthier vapers with a flippant “The plural of anecdote is not data”. Meanwhile his henchmen are offering serious money to find some quislings who are willing to publicly blame ecigs.
      [ http://antithrlies.com/2014/05/01/cdc-goes-full-orwell-in-opposition-to-tobacco-harm-reduction/ ]

      • Ros

        One of my greatest bug bears is that so many ‘researchers’ do not appear to understand the statistical tests they are using. Correlation does NOT confirm a causal relationship. Unfortunately, it is often misused/misinterpreted as such.

      • “The director of the same CDC dismisses thousands of (unpaid) statements of happy and healthier vapers with a flippant “The plural of anecdote is not data”. Meanwhile his henchmen are offering serious money to find some quislings who are willing to publicly blame ecigs.”

        Norbert, just as in the antismoking campaigns, they’re perfectly willing to say one thing out of one side of their mouth while saying the opposite out of the other. In “Brains” I called it, accurately I believe, classic Orwellian “Doublethink.” Use government force (taxes & laws) to make the TComps lower tar and nic for “health reasons,” and then sue them for lowering tar and nic because it has no effect on health. Big Pharma nic inhalers are healthy while TComp nic inhalers are deadly. Age laws “protect children” while age laws “make smoking more attractive to youth.” Smoking kills people early, but that doesn’t save on health care costs because smokers need to be calculated with equal life spans as nonsmokers. Research integrity is destroyed if researchers take money from Tcomps, but research integrity is untouched if the money comes from the $500 million in MSA funds or from Big Pharma.

        I could go on, but you get my point. Regardless of the fact that Antismokers/vapers use doublethink all the time, it still represents one of their more sensitive weak spots for attacks: show people how they lie, and people will, eventually, stop believing them. Print out, read, duplicate and distribute “The Lies Behind The Smoking Bans” at http://bit.ly/SmokingBanLies and and the excerpt from “Of Vapors And Vapers” at http://bit.ly/FDAstudy

        – MJM

  • Erik Befrits

    Dear Teemu, thanks a million for your reply. Very important issue this, exactly the same “impression” (wholly unscientific in most of their cases) is held by most who are opposed to e-cig as well. For affordableTHR to be made available in India and Africa for example, engineered low nitrosamine smokeless products (food grade) is one logical alternative as e-cig simply won’t be feasible for the poorer parts of the population. The problem (smoking) is global but the solution (alternatives) is regional, culture dependent and purchase power dependent. We in the west therefore have a responsibility to choose our wording carefully and inclusively when talking about THR. There are no registered snus fatalities in either Sweden nor Finland after more than 200 years of use. There are no signs of snus causing any cancers (above no tobacco use baseline) in eitherFinland or Sweden (or Norway for that matter). It is impossible to statistically differentiate quitting all nicotine from switching to snus in terms of health outcome. Take care and please continue your important help and work in lowering disease and death from combusted tobacco!! Br Atakan Befrits

  • Guy Eaton

    This neurotoxic argument is really silly as one of the few benefits of using nicotine is on the brain! It actually enhances cognitive functioning, unlike alcohol which really is a neurotoxin, causing cognitive deficits – nicotine actually does the opposite to alcohol. It should be alcohol that is banned for neurotoxic reasons? Nicotine is used in the treatment of dementia!!!! The arguments against nicotine are truly pathetic and bear not correspondence to reality. This scaremongering is so pathetic it is hard to motivate one to even argue against them.

  • Guy Eaton

    Further is the fixation on nicotine with some opponents, which is really misguided as nicotine is freely available in cigarettes and NRT anyway so nothing new just a different way of delivering it. What about flavoured gum made by GSK – will this attract children, or the little mint sweeties (i.e. lozenge). I think some people think nicotine was invented with the EC!!! Most of the arguments used against ECs are for unthinking people who read the Sun and Daily Mail…when they are analysed for a second they fall down entirely. I do wish opponents sometimes would come out with substantive arguments at least that would be interesting. They should stop waisting everyones time and help people.

  • Dave J

    I think too many people have a hard time separating nicotine from tobacco. Many comments, or accusations made against nicotine I have seen on various web chats clearly show that they say nicotine does (1,2 and 3) but in fact, it is the burning of tobacco that does those things. Reminds me of all the hype( but in reverse) caffeine pills got a while back. No one could understand why caffeine was dangerous, because in their eyes, caffeine was coffee and coffee was caffeine.

  • Bill Godshall

    On 22, Clive wrote:

    “If publicly funded ‘public health’ wants to become a temperance movement it needs to show that abstinence leads to harm reduction that provides value for money consistent with norms for public spending. If it is drawing on charitable funds (eg. from cancer or heart charities) it needs to ensure that abstinence – rather than harm through cancer or heart disease – is consistent with the relevant charitable objectives.”

    Unfortunately, public health agencies have been demonizing smokefree alternatives and advocating abstinence-only policies for several decades, beginning with the 1986 US SG report and the 1986 Comprehensive Smokeless Tobacco Education Act (which required false and misleading fear mongering warnings on all US smokeless products and prompted national, state and local health agencies to repeat them as talking points, which have deceived 90% of Americans to believe smokeless is as hazardous as cigarettes), and the EU snus ban during the 1990s.

    Obama’s DHHS has been trying to the same thing with e-cigs since 2009, when the FDA unlawfully banned e-cigs, and US Customs Agents seized nearly 1,000 shipments from US Ports.

    But the key reason why public health agencies in the US (and probably many other countries) have vehemently opposed THR for the past two decades has been aggressive lobbying of health agencies by Big Pharma funded groups in the US (i.e. CTFK, ACS, AHA, ALA, AMA, ADA, AAP, etc) to promote NRT and recently Wellbutrin and Champix as the only effective way to quit smoking, and to demonize and ban all smokefree tobacco/nicotine alternatives (that aren’t marketed by Big Pharma).

    Those charities and medical groups sold out to Big Pharma long ago, and they no longer care about reducing cancer, heart disease or lung disease caused by smoking.

    Similarly, the entire smoking cessation industry was created and is controlled by Big Pharma, and virtually everyone in the smoking cessation industry has been demonizing e-cigs (because they know e-cigs are likely to put them out of business).

    So the question is how do we better expose, confront and derail this unethical and inhumane conspiracy by Big Pharma, Big Government, the smoking cessation industry (and their allies in the news media) to demonize THR and ban smokefree alternatives?

  • David Friar

    Clive, this is an outstanding piece of work that seems to me very accurate, clearly argued and a superbly comprehensive summary of the key issues. So mostly I just wanted to add my voice to all those who have said thank you.
    I’ve got nothing really material to add, but one small part of the text that I think could be improved…. in point 19 you say ” yet the most successful products from a health perspective are the vapour, mods and tank type products “. To me at least the words ‘the vapour’ don’t really make sense here…. perhaps ” yet the most successful products from a health perspective are the rebuildable atomiser, mods and tank type products” might be better. Or is this whole sentence going too far? I’d like to think that it’s true that the products that give the user greater control over the experience are the ones that are most effective, but do we actually have any evidence for that?

    • john

      David
      On the whole, for people who make and/or market just about anything the statement: “the products that give the user greater control over the experience are the ones that are most effective,” is so true as to not, normally, need saying :-)

  • Jonathan Bagley

    I’m sure Dr Steele is sincere and trying to be helpful, but it seems, as someone else has mentioned, he isn’t aware of what the TPD contains. These facts can’t be ignored:

    i) all current refillable devices will be banned and a filling system which satisfies the TPD “leakage” requirements” is either impossible to devise or, at best, prohibitively expensive;

    ii) disposable cartridges of the maximum permitted strength of 20mg/ml typically deliver to the body the amount of nicotine equivalent to 6 or 7 cigarettes (not the 20 as claimed by the manufacturers). I know this from my own home mixing experience. The cost of vaping for a former 20 a day smoker will rise from around £3 or £4 a week with home mixing and a refillable device, to over £40 a week, which is £10 above the grey/black market tobacco price;

    iii) liquid strengths above 20mg/ml will be banned (in practice, nothing above 18mg/ml will be available). Vaping will not be a feasible option for former 30 or 40 a day smokers – those whose lives are most at risk.

    Unless we think the UK Government will ignore both the EU TPD and the MHRA, isn’t all discussion ultimately futile and of no relevance to all except light or occasional smokers whose habit isn’t doing them much harm?

  • Pat McManus

    Suffering from anxiety over issues of debates to ban vaping or regulate it. My husband is an over 50 year smoker, been coughing, getting lots of flu like symptoms. He was put on Champix which make him very ill and sick, so suddenly started smoking more when he stopped these tablets. However, since the 6th March started vaping and never touched a cigarette since. I am glad e-cigs are here and glad for there invention. They are only moaning about the nicotine, yet Cancer Research have stated that a cigarette has 4000 poisons that are harmful and nicotine wasn’t the problem.

    E cigs should have more support because it seems that nicotine patches and gum really have proved not to be 100% successful, why try to stop the next best thing on the market.

    • Guy Eaton

      Gum and patches are relatively ineffective (particularly patches for heavy smokers as a form of NRT). Sadly I believe this is one of the reasons ironically that ECs are not given more support, i.e. they are commercial rivals of ‘big pharma’ and ‘big tobacco’ (if the tobacco Companies have not already bought the Companies up). In addition, there are other commercial concerns such as tobacco tax revenue for the Government. I honestly think that anyone could give up with a really good brand EC, if they got used to it and used it properly. This ironically is the problem. NRT sales have already been significantly reduced by ECs – tobacco Companies are buying up EC Companies to try to reduce dents in their profits.
      Much of the negative information on ECs is in the form of propaganda generated by commercial rivals and other financial interests. Unfortunately gullible people lap this this up.
      In conclusion, if ECs were completely ineffective I don’t think that there would be any issue of banning, or medicalising.

  • Guy, VERY well summarized, and, from my own experiences/observations/readings, completely accurate.

    Nicely done in a very concise package!

    :>
    MJM

    • Guy Eaton

      Hello Michael

      thanks.

      I have keenly been looking at this area for a number of years now on a scientific and political level: I have unfortunately, come to these somewhat depressing conclusions – I am believe these to be fairly accurate! There is no other explanation other than mind boggling stupidity. In addition, although this really is a theory that may not have any validity on the ground, some Economists have expressed the view lack of EC support could also be related to burdens inherent to an ageing population and kid you not!!!!

      Guy

  • evaporate

    The TPD allows ecigs below 2% nicotine on the market without pharmaceutical marketing authorisation, but requires marketing authorisation above 2% nicotine. The TPD gives sweeping powers to governments to severely control products below 2%. WHO want to treat ecigs as tobacco products which enables governments to demonise and tax them. In europe that means products below 2% nicotine. The combined effect of the TPD and WHO appears to be to enable governments to punitive
    ly tax non pharmaceutical ecigs and ultimately make ecigs another pharma NRT product.

  • Christine May

    Questions to the opponents of e cigarettes…..

    I would love some answers to some important questions here.
    1] Why are you demanding proof of the safety of these products so vicariously when it is blatantly obvious that they are safer than tobacco?
    2] Why are you not expending your time and energy to get tobacco banned outright as the proof has been around long enough to know that it causes disease and death?
    3] Why are you ignoring “the evidence” as presented by thousands of ex smokers who have taken up vaping and almost immediately improved their health?
    4] Do you find it acceptable thtat over 2500 deaths have been directly attributed to Champix? If not why are you not trying to ban this product.
    5] Will you disclose the amount of profits made by the ineffective and painful treatment given to cancer patients.
    6] Will you disclose the incentives given to the medical fraternity by big pharma to promote ineffective NRT products.
    7] Why are you twisting the evidence to suit your own purposes, vaping is not smoking.
    8] Why are you persuing the illogical argument that vaping is a gateway into smoking, which is ridiculous?
    9] Why can you not see that by banning e cigarettes you are commiting modern day genocide?
    10] Why can you not see that many people who smoke are in the lower socio economic class and would benefit strongly from vaping?

    Lastly, please could you spend your efforts on educating the public about nutrition. Obesity is going to be the next killer, foods are full of additives and sugar which are destroying a whole generations health. Please leave us in peace to enjoy a wonderful new recreational product which is improving our health on a daily basis.
    Kind Regards
    C J

    • I agree, honest answers to your questions would be revealing. So, don’t hold your breath …

      But on your last comment about obesity: Becareful what you wish for!

      This is already on the list of the Worlsd Harm Organisation! And there is already talk about how to apply methods from tobacco control to obesity. Since they worked so well. So you can see, the campaigns to demonise fat people – pardon, “denormalize obesity” – are already starting. I recently read, there are already some jerks constucting “second hand fat” -> Shun fat people, because their proximity might normalize obesity. And they eat like pigs.

      I don’t have anything against sensible, science based advise. But I’m afraid, all we’ll get will be the same kind of propaganda that already Hitler and his happy helpers like Göbbels used to demonize smokers. Which is now applied to vapers and sure will be applied to people they call obese.

      And of course they will totally ignore all scientific evidence that might indicate that people who are slightly overweight have the best life expectancy.

  • Christine May

     
    Hi Everyone,
     
    Could I please ask you to spare a couple of seconds to sign this petition. The WA Health Department, backed unbelievably by The Cancer Council of Western Australia have prosecuted a small trader (Heavenly Vapours) who was selling personal vaporisers (otherwise known as e cigarettes)
    Personal Vaporiser’s or E-Cigs are electronic devices that can be used as a less harmful way for existing smokers struggling with addiction to get their nicotine. Dozens of studies have been done that clearly demonstrate that these devices are orders of magnitude safer than smoking tobacco cigarettes. The law here needs to be updated or corrected – It was never intended when parliament created this law that it block a life saving technology! No member of parliament would ever pass a law that would mandate millions of people have no choice other than to quit or get sick and die!
    This appeal simply must be won if it is not, it will set a legal precedent, which will then spread like a cancer all over the world, which will mean the unnecessary loss of millions of lives. This to me is akin to a modern form of genocide!
     
    Unfortunately it appears that $$$MONEY$$$ is more important than PEOPLES LIVES
    It appears to be more important to protect the vested interests of pharmaceutical companies, who profit from selling 95% ineffective nicotine replacement therapies than it is to SAVE LIVES.
    It appears to be more important to look after the big tobacco companies, who are losing revenue and market share than it is to SAVE LIVES.
    It appears to be more important to protect the government’s ever increasing tobacco tax revenue than it is to SAVE LIVES.
    And although this may sound extreme, apparently for every person who gets cancer there are, I understand, profits of up to around $50,000 to be made by the medical fraternity, this too unbelievably appears to be more important than it is to prevent cancer and SAVE LIVES.
     
    I myself smoked for 47 years and I could feel it was killing me. The final straw was when I was coughing so much at night that I became incontinent! Then I felt totally helpless and suicidal.
    Three months ago I purchased a personal vaporiser and have gone from smoking 35-40 cigarettes to zero and my health is improving tremendously. My cough disappeared within a few days, I can now easily walk for an hour, whereas before 5 minutes was my maximum.
     
    I have suffered from severe anxiety attacks for over 30 years plus depression, but in the last couple of weeks, my anxiety has almost disappeared. I used to think that smoking was calming me down, but now I realise that all the chemicals in the cigarettes were making me worse. It was the nicotine which calmed me down and I can still get that through vaping.
     
    I have recently learned that smoking actually reduces serotonin levels, so I was fighting a losing battle.
     
    There are over 4000 toxic ingredients in cigarettes, but just 4 ingredients in the juice which we vape, none of which have been proved to be harmful.
     
     Thanks for reading this message and if anyone would like to make a small donation to the fundraising the link is below.
     
    I feel very uncomfortable asking for anyone to donate, as it may appear I am some sort of scammer. I have received over 130 signatures in the first week, but few donations to the cause. I thank all of you for your support, but we need funds too as time is quickly running out for the appeal and unless enough money is raised it may not go ahead.
     If any of you have doubts as to my integrity please just Google Heavenly Vapours to find out the situation for yourselves. Even a couple of $’s could make all the difference.
    There are few times in our lives where our actions can affect the lives of so many others…
    This is YOUR CHANCE to make a difference, MILLIONS OF LIVES ARE AT STAKE. Please stand with me, we cannot let greed win out over our right to health and free choice.
    Please share this message on your facebook and/or twitter to get our voices heard.
     
    Warm Regards,
    Christine
    To sign the petition please click the link below,
    Petition to West Australian Health Minister
    To Donate please click the link below J
    http://www.gofundme.com/Ecigs-Our-Right-to-Choose
     
     

  • Michael J McFadden

    Christine, I am not an opponent of vaping, but I’m a very long-term opponent of those opponents — since they virtually all cut their baby teeth as being Antismokers. So, although I’m sure you know many of the answers to the questions you ask, let me give you my perspective on what the Antivapers HONEST responses might be:

    Q1] Why are you demanding proof of the safety of these products so vicariously when it is blatantly obvious that they are safer than tobacco?
    A1] Because vaping looks like smoking and people enjoy it the same way as smoking. And we know that absolute proof of a negative (like “Reasonable secondhand smoke exposure is not harmful.”) is impossible, so demanding absolute proof of vaping’s safety will help stop vaping.

    Q2] Why are you not expending your time and energy to get tobacco banned outright as the proof has been around long enough to know that it causes disease and death?
    A2] It’s still too hard: we need to reduce the number of smokers sufficiently for a Final Solution to take place. Vapers are still a small enough population that they can be eliminated if strong action is taken at the start.

    Q3] Why are you ignoring “the evidence” as presented by thousands of ex smokers who have taken up vaping and almost immediately improved their health?
    A3] Because the evidence conflicts with our goal and message.

    Q4] Do you find it acceptable thtat over 2500 deaths have been directly attributed to Champix? If not why are you not trying to ban this product.
    A4] 2500 deaths is fully acceptable. We (remember, “we” here is referring to the Antismokers and Antivapers… not me!) have no problem with that number: it’s collateral damage.

    Q5] Will you disclose the amount of profits made by the ineffective and painful treatment given to cancer patients.
    A5] No. And you can’t make us. :P

    Q6] Will you disclose the incentives given to the medical fraternity by big pharma to promote ineffective NRT products.
    A6] No. And you can’t make us. :P

    Q7] Why are you twisting the evidence to suit your own purposes, vaping is not smoking.
    A7] We twist the evidence about vaping the same way we twist it about secondhand smoke. The end justifies the means. And vaping LOOKS like smoking, did you forget that already???

    Q8] Why are you pursuing the illogical argument that vaping is a gateway into smoking, which is ridiculous?
    A8] We’re doing it because it’s an effective argument when repeated over and over and over again in the media that we buy. The more ridiculous a lie is, the easier it is to convince people that it MUST be true!

    Q9] Why can you not see that by banning e cigarettes you are committing modern day genocide?
    A9] Acceptable losses. They’re only smokers.

    Q10] Why can you not see that many people who smoke are in the lower socio economic class and would benefit strongly from vaping?
    A10] They should get better jobs or quit smoking with taxpayer paid Big Pharma products. And if they don’t? Well, they’re only smokers, or did you already forget that too?

    Christine, I wish you the best in your efforts: you’re up against a very powerful, very well-financed, and very entrenched set of foes who are coming into this fight from a whole set of different motivations. See: http://bit.ly/braintypes

    They CAN be fought because we understand their tricks and techniques a helluva lot better now than we did 30 years ago, but on the other hand, they’ve got a helluva lot more money now than they did then. (I’d guess that ASH et al had at *most* a couple of hundred thousand dollars in 1974. According to the AMA, the “Tobacco Control” folks (which now includes “Vaping Control”) has been getting $500 million to $900 million PER YEAR just from smokers’ MSA taxes over the past 15 years.)

    Keep on fightin’!

    – MJM

    • I think the answers to
      Q4] Do you find it acceptable thtat over 2500 deaths have been directly attributed to Champix? If not why are you not trying to ban this product.
      will be more of a global evasive manoeuvre by spreading the blame.

      CRUK and other crooks: The product has a medicinal licence by FDA, MHRA, and all those other (govern)mental propaganda agencies. It is their responsibility to evaluate risks and benefits. We just endorse what they deem reasonably safe.

      FDA, MHRA, and their pals from the pharmafia: It’s the responsibility of the doctors prescribing these drugs to check for possible side effects. Besides: These filthy smokers could have chosen other medicinally approved useless product. It’s their own fault. There is a strong warning (now) about possible side effects.

  • Christine May

    Dear Michael,
    I love your tongue in cheek answers. You have hit the nail right on the head.
    We simply MUST keep fighting, although it is certainly an uphill battle.
    Thanks so much for giving your time and support to this cause.
    Warm Regards
    Christine

  • Christine May

    I have no problem with fat people. I guess what I am more concerned about is the misleading labelling on products which are sold to these poor people who wish to slim down. The blatant profiteering of the food industry who hide ingredients and additives.
    I think you are worried about even more control, but honestly all these kids being put on drugs for ADHD could be”cured” if their parents stopped buying all these fizzy drinks and junk food for them. Advertising junk food to children is a much bigger profitable industry than e cigarettes could ever become in my humble opinion.

  • Thank you, excellent summary.

    I think there is something wrong with this sentence in section 2. though — at least I couldn’t understand what it was supposed to say:
    “It is possible that nicotine is unhelpful you already have cancer.”

  • Tom Teasdale

    Hi , Another suggestion for the Q n A –

    “The EU has decided that e-cigs need to be regulated so they must be bad right ?”

  • John

    Clive I think that the only creditable if small risk in the whole scenario is ‘ flavourings’. And that is not a intrinsic or fatal problem.
    Am doing more diging ( second nature to this of a historical bent) will keep you informed .

  • John

    Blowsy spill chick ” to those of a historical bent” is what meant

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